A recent Cochrane review found that school feeding programmes significantly improve the growth and cognitive performance of disadvantaged children. Trisha Greenhalgh,Elizabeth Kristjansson, and Vivian Robinson look more closely at the highly heterogeneous trials to see what works, for whom, and in what circumstances. \u00a9 2007, BMJ Publishing Group Ltd. All rights reserved.
\n \n\n \n \nObjective: To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school. Design: Focus group study. Setting: Six London secondary schools. Participants: 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds. Main outcome measures: Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support. Results: There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards \"posh\" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfilment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices. Conclusions: Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
\n \n\n \n \nThis is a systematic review on how innovations in health service practice and organisation can be disseminated and implemented. This is an academic text, originally commissioned by the Department of Health from University College London and University of Surrey, using a variety of research methods. The results of the review are discussed in detail in separate chapters covering particular innovations and the relevant contexts. The book is intended as a resource for health care researchers and academics. \u00a9 2005 by Blackwell Publishing Ltd.
\n \n\n \n \nObjective: To develop and refine a complex intervention for diabetes support and education in minority ethnic groups, delivered through bilingual health advocates. Design: Action research framework-a variety of methods used in an emergent and developmental manner, in partnership with clinicians, managers, and service users, drawing especially but not exclusively on narrative methods. Setting: Deprived inner London district Interventions: Development and evaluation of three components of the complex intervention: a group based learning set for bilingual health advocates, in which stories about clients with diabetes formed the basis for action learning; advocate led support and education groups for people with diabetes, which used personal stories as the raw material for learning and action; organisational support to help to develop these new models and embed them within existing services. Results: Both advocate groups and user groups were popular and well evaluated. Through storytelling, advocates identified and met their own educational needs in relation to diabetes and the unmet needs of service users. In the advocate led user groups, story fragments were exchanged in a seemingly chaotic way that the research team initially found difficult to facilitate or follow. Stories were not so much told as enacted and were often centred on discussion of \"what to do.\" Whereas some organisations welcomed, successfully implemented, and sustained the advocate led groups, others failed to do so. A key component of the complex intervention was organisational support. Conclusions: An action research approach allowed engagement with an underserved group of health service staff and with hard to reach service users. The study produced subjective benefits to these groups locally as well as a worked-up complex intervention that will now be formally tested in a randomised controlled trial.
\n \n\n \n \nThe success of evidence based medicine has led to pressure to make medical education more evidence based. Greenhalgh and colleagues tested the transferability, of these principles when developing a postgraduate course.
\n \n\n \n \nIt is possible to be seriously misled by taking the statistical competence (and/or the intellectual honesty) of authors for granted. Some common errors committed (deliberately or inadvertently) by the authors of papers are given in the final box.
\n \n\n \n \nObjectives: To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement. Design: Illuminative evaluation. Setting: Targeted email and networking service for UK healthcare practitioners and researchers. Participants: 2800 members of a networking service. Main outcome measures: Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service. Results: The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest. Conclusion: This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; tight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation.
\n \n\n \n \nGeneral practitioners and other primary care professionals have a leading role in contemporary health care, which Trisha Greenhalgh explores in this highly praised new text. She provides perceptive and engaging insights into primary health care, focussing on: \u2022 its intellectual roots \u2022 its impact on the individual, the family and the community \u2022 the role of the multidisciplinary team \u2022 contemporary topics such as homelessness, ethnic health and electronic records. Concise summaries, highlighted boxes, extensive referencing and a dedicated section on effective learning make this essential reading for postgraduate students, tutors and researchers in primary care. From the foreword by Julian Tudor Hart \"Trish Greenhalgh, in her frequent columns in the British Medical Journal...more than any other medical journalist spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science. When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947-52, the advance is stunning.\" \"Trish Greenhalgh is one of the international stars of general practice and a very clever thinker. This new book is a wonderful resource for primary health care and general practice. Every general practice registrar should read this book and so should every general practice teacher and primary care researcher.\" Professor Michael Kidd, Head of the Department of General Practice, University of Sydney and Immediate Past President of The Royal Australian College of General Practitioners \"This important new book by one of primary care's most accomplished authors sets out clearly the academic basis for further developments in primary health care. Health systems will only function effectively if they recognise the importance of high quality primary care so I strongly recommend this book to students, teachers, researchers, practitioners and policy makers.\" Professor Martin Marshall, Deputy Chief Medical Officer, Department of Health, UK. \u00a9 2007 Trisha Greenhalgh.
\n \n\n \n \nObjective: To evaluate the impact of telling patients their estimated spirometric lung age as an incentive to quit smoking. Design: Randomised controlled trial. Setting: Five general practices in Hertfordshire, England. Participants: 561 current smokers aged over 35. Intervention: All participants were offered spirometric assessment of lung function. Participants in intervention group received their results in terms of \"lung age\" (the age of the average healthy individual who would perform similarto them on spirometry). Those in the control group received a raw figure for forced expiratory volume at one second (FEV1). Both groups were advised to quit and offered referral to local NHS smoking cessation services. Main outcome measures: The primary outcome measure was verified cessation of smoking by salivary cotinine testing 12 months after recruitment. Secondary outcomes were reported changes in daily consumption of cigarettes and identification of new diagnoses of chronic obstructive lung disease. Results: Follow-up was 89%. Independently verified quit rates at 12 months in the intervention and control groups, respectively, were 13.6% and 6.4% (difference 7.2%, P=0.005, 95% confidence interval 2.2% to 12.1%; number needed to treat 14). People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group. Cost per successful quitter was estimated at \u00a3280 (\u20ac365, $556). A new diagnosis of obstructive lung disease was made in 17% in the intervention group and 14% in the control group; a total of 16% (89/561) of participants. Conclusion: Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear. Trial registration: National Research Register N0096173751.
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